tv Medicare for All House Hearing CSPAN April 30, 2019 10:23am-12:00pm EDT
>> the house rules committee is holding a hearing this morning for medicare for all, a bill to create a national health insurance program under medicare. this is the first congressional hearing for the medicare for all policy. we join it in progress. mr. mcgovern: unionization of the car wash industry. he graduate interested yale law school and columbia college couple laudy, as i said in my opening statement, we are deeply honored to have you mere. nd the floor is yours. >> chairman mcgovern and members of the committee, thank you for inviting me to testify today. my name is audi barkin. i am 35 years old and i live in santa barbara, california, with my brilliant wife rachel and our beautiful toddler. she's an english professor at
the university of california, santa barbara and i am an organizer at the certainty for popular democracy and the be a hero project. i earned my bachelor's degree from columbia university with a major in economics and my yaw degree from yale law school. over 20 years since i was a freshman on my high school debate team, i have been giving speeches and presentations on topics like health care reform and the federal budget. but never before have i given a speech without my natural voice. never before have i had to rely on a synthetic voice to lay out my arguments. my most passionately held beliefs, tell the details of my personal story. three years ago rachel and i felt like we had reached the mountaintop. we had fulfilling careers. a wonderful community of friends and family, and a smiling, chubby infant boy. we could see decades of happiness stretching out before us. the sun was shining a and there was not a cloud in sight.
and then out of the clear blue sky we were struck by lightning. a.l.s., a mysterious neurological disease with no cure and no good treatment, a life expectancy of three to four years, most of its victims are in their 50's and 60's. i was 32. every month since my diagnosis my motor neurons have died out, my muscles have disintegrated and i have become increasingly paralyzed. i am speaking to you through this computer because my diea frame and tongue are simply not up to the task. although my story is tragic, it is not unique. indeed, in many ways it is not so rare. jennifer, the president of my organization, is sitting next to me. like me, her husband was struck at a young age by a neurological disease. multiple sclerosis, 10% of americans have a serious
disability, every family is eventually confronted with serious illness or accidents. on the day we are born and on the day we die and on so many days in between, all of us need medical care. and yet in this country the wealthiest in the history of human civilization, we do not have an effective or fair or rational system for delivering that care. i will not belabor the point because you and your constituents are well aware of the problems, high cost, bad outcomes, mind-boggling bureaucracy, racial disparities, bankruptcies, fweeo graphic inequities, and obscene profiteering. the ugly truth is there. health care is not treated as a human right in the united states of america. this fact is outrageous. and it is far past time that we change it. say it wloud for the people in the back, health care is a human right. for my family, although we have comparatively good private health insurance, a.l.s. now
means paying out of pocket for almost 24-hour home care. this costs us $9,000 every month. the alternative is for me to go into medicare and move into a nursing home away from my wife and my son. so we are cobbling together the money from friends and family and supporters all over the country. but this is an absurd way to run a health care system. go fund me is a terrible substitute for smart congressional action. like so many others, rachel and i have had to fight with our insurer, which has issued outrageous denials instead of coverage the benefits we paid for. we have so little time left together, and yet our system forces us to waste it dealing with bills and bureaucracy. that is why i am here today. urging you to build a more rational, fair, efficient, and effective system. i am here today to urge you to enact medicare for all. there are three simple reasons why medicare for all is the
right solution. the only solution to what ails the american health care system. i will summarize them here, but i urge you to read the fantastic testimonies commit smithed by the national nurses united for more details. first, medicare for all will deliver to everyone living in america the high quality care that we deserve. the law will provide comprehensive care including primary and hospital care, dental, vision, reproductive, and mental health care. we will all be allowed to see the doctors and specialists we want. and crucially, the program will provide for long-term services and supports that will allow people like me to stay in our homes and communities with the people we love. this will dramatically improve life for the tens of millions of people whose families include older or disable people. second, medicare for all will save the american people enormous sums of money. under the program there will be
no premiums, no deductibles, and no co-pays. that means that we will no longer need to choose between paying the rent and filling a prescription. it means we will no longer delay necessary care until it is tragically late and tragically expensive. it means that we won't have to worry every year when our employer announces the new rates. it means that we can finally start to eliminate the atrocious racial and economic disparities that destroy so many lives, that rob our communities of so much dignity, that strip us all of our common humanity. any proposal that maintains financial barriers to care, any proposal that continues to charge patients co-pays, deductibles, and premiums will leave people out. any proposal that maintains the for-profit health insurance system will require that some people don't get the health care they need. without the generous support of my family and friends, this would include me.
crucially, medicare for all is the only way to make our health care system more efficient. over the past three years, i have seen firsthand how the current system creates absurdly wasteful cost shifting, delays, billing disputes, rationing, and worry. administrative waste is costing us hundreds of billions of dollars every year. medicare for all will streamline the entire system letting doctors and nurses focus on delivering care instead of on paperwork. as a single payer program, medicare for all will be able to eliminate immoral price gouging by pharmaceutical and device companies. the fundamental truth is that too many corporations make too much money off of our illnesses, and they are spending gazillions of dollars loniing and fighting to stop us from building something better. it is very important to emphasize the following point. these cost savings are only possible for a medicare for all system.
other proposal to increase health inshureges coverage such as those that would make medicare compete with private insurance, would not facilitate administrative and billing savings. there are many other major benefits to medicare for all detailed in the written testimony submitted by the nurses and others. but my time to deliver this testimony is running out, and in a much more profound sense, my time to deliver this message to the american people is running out as well. so i want to end on this third and final note, our time on this earth is the most precious resource we have. a medicare for all system will save all of us tremendous time. for doctors and nurses and providers, it will mean more time giving high quality care. and for patients and our families, it will mean less time dealing with the broken health care system and more time doing the things we love together. some people argue that although medicare for all is a great
idea, we need to move slowly to get there. but i needed medicare for all yesterday. millions of people need it today. the time to pass this law is now. winning this reform will not be easy. the moneyed interests will do everything in their power to stop us. yet despite these obstacles and despite the personal challenges that i face, i sit before you today a hopeful man, a hopeful husband, and hopeful father. i am hopeful because right now there is a mass movement of people from all over this country rising up. nurses, doctors, patients, caregivers, family members we are all insisting that there is a better way to structure our society. a better way to care for one another. a better way to use our precious time together. and so my closing message is not for the members of this committee, it is for the american people. join us in this struggle. be a hero for your family, your
communities, your country. come give your passion and your energy and precious time to this movement. it is a battle worth waging. and a battle worth winning. for my son, carl, for your children, and for our children's children. we have a once in a generation opportunity to win what we really deserve. no more half measures. no more health care for some. we can win medicare for all. this is our congress. this is our democracy. and this is our future for the making. mr. mcgovern: thank you very much. >> chairman mcgovern and members of the committee, thank you for inviting me to testify today. my name is ady barkann. mr. mcgovern: thank you very much. i appreciate t we are grateful for your testimony -- i appreciate it. we are grateful for your
testimony and honored to have you here. yield to mr. cole. mr. cole: it's a great privilege to have you here at considerable sacrifice and risk to yourself. testament to your courage. very happy and honored to have you and-n this debate and hearing today. thank you. we'll go next to dr. charles playhouse. jake fish and lillian f. smith chair and senior research strategist at the mcadis at george mason university, and a visiting fellow at stanford university inconstitution, previously served as a public trustee for the social security and medicare programs. deputy director of the national economic council under president george w. bush. >> thank you very much. chairman mcgovern. ranking member cole, all the members of the committee, greatly appreciate this opportunity to appear before you
to discuss the estimated federal budget costs of medicare for all. before i proceed to the estimates, just a few caveats. this is not anal nacies of whether medicare for all is good policy or bad policy. it's a cost projection. as i discuss the factors that play into them, it's by way of explaining had you they affect the numbers. second is my testimony is based on an analysis of the medicare for all act of 2017, introduced by senator sanders in the last congress. obviously there are more recent bills introduced by representatives jya paul and senator sanders himself, these rex spected to cost more. but i have not had an opportunity to analyze these bills. medicare for all would add somewhere between $32.6 trillion and $38.8 trillion in new federal budget costs over the first 10 years. the $32.6 trillion estimate lower. it essentially assumes every cost containment provision in the bill saves as much as
possible. if things play out with historical trends, the new costs would be $38.8 trillion. i'll say more about this later. such enormous numbers are difficult to grasp. we are talking about 11% to 13% of our g.d.p. in 2022, rising to 13%, 15% in g.d.p. in 2031 being added to the federal ledger. we do the not have historical experience with permanent government expansions of this size. to provide a sense of the magnitude, the study notes doubling all current individual and corporate income taxes would be insufficient to finance the lower bound estimate. now, to be clear, these would not be the total costs of medicare for all. this would be the federal government's new cost above and beyond currently projecting -- projected health obligations. it would be somewhere between $54. trillion and $64.7 trillion. the vast majority of the costs
would arise from the government of health spending by others by state and local government, private insurance, and individuals in the payments out of pocket. other aspects of medicare for all would add to that existing health fend spending. still others are intended to bring costs down. the biggest factor increasing health spending under medicare for all would be its expansion and increased again rossity of health insurance coverage. spending on behaft of the currently uninsured would rise, as one would expect and presumably intend. additional benefits would be provided that medicare currently doesn't. such as dental, vision, and hearing services. perhaps most importantly, as has been noted here, medicare for all would provide first dollar coverage of all americans' health expense, meaning no deductibles, co-pace, or cost sharing this. would considerably increase the demand for health service force the well documented fact the more people's health care financed by their insurance, the more they consume. under medicare for all, the federal government would not only take on responsibility for
funding currently projected health services, but a significantly increased demand. other provisions of medicare for all are expected or hoped to reduce costs. the study assumes substantial administrative cost savings from eliminating private health insurance. and the brackets a range of possible outcomes of efforts to negotiate lower drug prices. the big variable here is payment rates for health providers. the bill indicates providers will be paid at medicare payment rates. these are are lower than those paid by private insurance. hospitals, payment reductions will be more than 40% for treatments now covered by private insurance. for doctors the reduction from private insurance rates would start out around 30% on average. they grow steeper over time reaching 42% in 10 years. importantly these reduced payment rates would be substantially below providers reported cost of providing services. we do not know what would happen to the supply, time limits, or quality if we were to impose sudden provider payment cuts of this magnitude while
simultaneously increasing the demand. because of this, several other studies performed prior to the bill's introduction assumed higher payment rates than medicare would be needed. my study did not take side on whether these provider payment cuts would be desirable. surely from an analytical standpoint you have to recognize the much larger a and more sudden the lawmakers have been willing to implement. if historical patterns continued, medicare for all would further increase national health spending even above current projections. my written testimony provides comparisons shown these timents are similar to other experts when you adjust for the years being estimated and alternative assumptions regarding administrative costs, prescription drug cost, and provider payment rates. i hope this information is useful. i thank the committee again for the opportunity to discuss these important aspects of medicare for all. mr. mcgovern: thank you very much. dean baker is an commayings and co-founder of the center for economic and policy research in
washington, d.c. his areas of research include houses, microeconomics, intelligent support, social security, medicare, and european labor markets. he's the author of several books and his piece "medicare for all is not fanta can i si" was published on cnn's website. he received his b.a. from swaftmore, and ph.d. in economics from the university of michigan. great to have you here. >> thank you chairman mcgovern and ranking member cole. i appreciate opportunity to speak here. i have to say it's a a great honor to be next to ady again. i knew him from prior days when we were in the coalition to pressure the fed to allow more full employment. that was amazing effort that he deserves credit for in addition to his subsequent work. i want to make three main points and say a little about the transition. first i want to say that medicare for all is affordable. that the bulk of the payments
should be coming from shifting employer premiums to government basically to taxes. it's not additional money out of workers' pockets. secondly, that the much additional -- that the amount of additional revenue, here what we have to keep front and center we pay twice as much for everything as everyone else in the world that. doesn't make sense. the third point is that lower costs can can be associated with better care, not just for the obvious reason that will increase access, but for other reasons we should expect better outcomes. the first point, in terms of the overall affordability, taking a look at the numbers, basic story cop prabble that you are looking at incore praretting somewhere, looking at 2021 to 2030. incorporating the private payments into -- under the government budget, about $33.4 trillion by my calculations using c.m.s. numbers. first off we know that there will be a lot of administrative
savings. there was an analysis done back our 03 that compared administrative costs with canadian administrative costs. most obviously you have the huge difference in what we actually pay up front for insurance, but in addition to that, we have huge administrative costs on providers, hospitals, doctors office, nursing homes. they have to have large numbers of staff to deal with different billing from different insurers. using their figures i calculate that we would get that tab down to $25 trillion. still considerable. that's shown in table one of my written testimony. second point, second adjustment we will see more utilization. i think -- we are shooting in the dark here because we don't know what happens when we make more health care for cheap for people. the important point to keep in mind, 70% of our health care costs come from rough-i 10% of the population.
the point is those 10% are either on medicaid or they have hit their out-of-pocket limits. in other words, they are not already constraint. we are looking at 30% of costs. how much more will that with go up? we tonight know. i assumed 10% in the calculations. we also, there will be some out of pocket. that will be debated how much you have 1% of g.d.p. that leaves us after we account for the $11.6 trillion in employer payments we are left with $13.6 trillion. still a substantial bill over a a decade. ok what, about input costs? i won't go into these in great detail, it's in my testimony, if we look at our cost, if we took through medical equipment, prescription drugs, physicians payments, dentists, we pay twice as much as everyone else in the world l we get down to other levels? that's an open question. but there is no obvious reason we should be paying twice as much for our drugs, for our medical equipment as people in france and germany. we don't pay auto workers twice
as much. or twice as much for cars. it's not clear why we do that for health care. low me focus on prescription drugs, c.m.s. expects we'll spend $6. trillion in prescription drugs. most people analyzed we can can get that down. one of the points i like to make we are not talking about making prescription drugs cheap, we are making them expensive. drugs would be cheap if we didn't give government granted patent mon no plis. i understand there is a rationale for that. the point is we could fund the research in alternative ways a and they would be cheap. to come quickly to last points, we could expect better care, people shouldn't have to deal with the stress. ady and his family should have to deal with the stress of paying for their bills that. has to be a negative in terms of care for someone. cancer victim. someone else suffering from a a serious disease they have to deal with with with bills. also in the case of prescription drugs, our opioid problem, at least it's alleged, is the result of our patent monopolies.
purdue phrma would not have done, push their drugs insisting it wasn't addictive when the evidence was it is. we have helped create that problem. i would be cautious on how you do it. first off fix medicare it's absurd that we don't have an out-of-pocket limit on traditional medicare. we need that. secondly, not incore praretting the drug benefit. we don't have stand alone drug plans in the private sector. why do we have that in medicare? that raises costs. we overpay the medicare advantage plans. recent analysis found we overpay them by roughly $13%. -- 13%. allow a buy in. have a competitive medicare plan. third put, reduce input prices. i can introduce lots of ways to do that. public funding for research for prescription drugs. lastly, very, very simple first step, how about lowering the
medicare age of eligibility 64. that's very affordable. a lot of 64-year-olds are already on medicare through disability or on medicaid. a great down payment in my view. long and short, i think it's affordable, but we have to be careful how we get there. thank you. mr. mcgovern: thank you very much. mr. cole: thank you very much. miss grace is president of the i.n.s. actual of a public policy organization founded in 1995 to provide and informed debate over free market ideas for health reform. she's been instrumental in developing and promoting ideas for reform to transfer power over health care decisions to doctors and patients. she speaks and writes extensively about incentives to promote more competitive patient centered marketplace in the health sector. >> thank you ranking member cole, thank you chairman mcgovern, members of the committee for the opportunity to testify today. let me begin by saying i believe
there are important shared goals for health reform. everyone should be able to get health coverage to access the care they need. it should be affordable. people should be a able to see the doctors they choose. quality of care. and we must protect the most vulnerable with the strong safety net. millions of americans are frustrated with the current system. care costs too much. and many are simply priced out of the market. others with insurance they claim deductibles are so high they might as well be uninshired. those on public programs struggle to find physicians, especially specialists who can can afford to take the prament's low payment rates. people are hurting and they feel powerless. as cogs in the $3.6 trillion health sector with little power to impact choices or costs. but it is hard to see how consumers would be more empowered when dealing with a
single government payer in a country that values diversity, where one massive program, with one list of benefits, and one set of rules work for everyone. i was in the gallery the night the house passed the affordable care act in march of 2010. and heard member after member talk about the importance of passing the bill in order to finally achieve universal coverage and to lower costs. nine years later with millions still uninsured and costs doubling in the individual market, our nation is still struggling to achieve those goals. here today you acknowledge the growing interest in this proposal, but when people learn that medicare for all would mean much higher taxes and losing the coverage they have now, support plummets. what happened recently in colorado and vermont when they tried and failed to create their own single payer system i think is important to staudy.
i believe the growing presence of government in the house sector is a consistent, is a significant contributor to its dysfunction. government officials not consumers increasingly determine what services can can or must be covered, how much will be paid, who is eligible to both deliver and receive these services. third party payment systems lead to significant disruptions. insurers others must respond to government rules, shoving consumers to the bottom of the health care totem pole. rather than expand the role of government, i believe we need to look more carefully at these problems and target appropriate solutions that empower consumers a and build on what works. medicare for all's promise of unrestricted access to benefits is virtually unprecedented, and it is difficult to anticipate the impact of this new system. representative jayapal's bill implies a recognition of cost bice imposing global budgets to
contain spending. paying doctors and hospitals at medicare rates would force many to close or significantly cut back on services. and would worsen the existing physician shortage. we do know from the experience of other countries that centrally determined benefit structures leads to rationing, waiting lines, and lower quality of care as i describe in my testimony. tragically it is often the most vulnerable who are left behind when demand for sr. have is -- services outpaces resources. many americans would he see this severely disrupted to lose their current coverage on public programs as well as job-based health insurance would be shut down under medicare for all. 173 million americans get health coverage through the workplace. a highly valued benefit. my colleague explains that this system is really a central pillar in our health sector. it produces nearly three to one
ratio in value to tax expenditures. employer plans also pay doctors and hospitals more than medicare. and providing the margins most need to maintain quality and even keep their doors opened. employers also have more flexibility to tailor insurance to the needs of those in the work force to advocate for them and provide education can and incentives about good health. i describe in my testimony targeted solutions already under way to give individuals and workers more not fewer choices, a and to provide states with more resources and flexibility to help their health insurance markets recover. i also describe work by the health policy consensus group in developing a plan to reduce the cost of health insurance while protecting the poor and sick, including those with pre-existing conditions. finally, americans want more not fewer choices in health coverage. yet medicare for all would put
them on a single government program. when government officials are making decisions about what services will be covered a. the legislation explicitly says, how much providers will be paid, how much they must pay in mandatory federal tax, consumers will have even fewer choices than they do today. it will reduce access to new technologies, stifle innovation, and result in a near doubling of the tax burden. i would welcome the opportunity to work to achieve the goals of better access to more affordable coverage and better protection for the vulnerable. thank you for opportunity to testify. mr. mcgovern: thank you very much. dr. sarah collins is vice president for health care coverage in excess of the commonwealth fund. she directs the fund's program on insurance coverage and access. dr. collins has led several multiyear surveys on health insurance and offered reports, issued briefs on health insurance coverage, health reform, and the affordable care act. early she was associate editor
at the "u.s. news and world report." senior health policy analyst in the new york city office of the public advocate. dr. collins holds an a.b. in economics from washington university, and ph.d. in economic from george washington university. thank you for being here. doctor collins: thank you, mr. chairman, and members of the committee for being able to testify on proposals to reform the u.s. health system. my commeents are going to focus on gains. the problems people continue to report. and potential of recent congressional bills to address these problems. the a.c.a. brought sweeping change to the health system. expanding comprehensive health insurance to millions of americans and making it possible for anyone with health problems to get coverage by banning insurers from denying coverage for charging more because of pre-existing conditions. the number of uninsured people has fallen by nearly half since the a a.c.a. became law.
there's been a decline in the share of people reporting problems paying medical bills or not getting care because of cost. the large combroid of research on the a.c.a. shows that the law's overall impact on people's ability to afford insurance and get health care has been positive. however, three distint yet interrelated problems remain. 29.7 million people remain uninsured. 44 million people with insurance have plans that are leaving them under insured. and health care costs are growing faster than median income in most states. the stalled gains in coverage stem from five primary factors, 17 states have not yet expanded medicaid. people of incomes just over the eligible threshold for marketplace subsidy, and many in employer fans have higher premium costs. congressional and executive actions on the individual market and medicaid have reduced potential enrollment in both. undocumented immigrants are ineligible for subsidized
coverage. and cost sharing is climbing in individual market and employer plans. a major factor underlying trends in both uninsured and underinsured rates is close and health care cost, health care costs are the pry mare driver of premium and deductible growth in private insurance. there is growing theafed major cost of health care cost growth are prices paid to providers, especially hospitals. there is evidence these prices explain the wide health care spending gap between u.s. and other wealthy countries. and there is also evidence that the greatest provider of price growth is occurring in private insurance. congressional democrats have introduced several bills to address these problems. the bills all propose to expand the public dimensions of private and public health system and grouped into three categories. built to add more public plan features to private insurance such as enhancing marketplace subsidies. bills that give people a choice
of public plans alongside private plans such as plans based on medicare or medicaid offered through the marketplaces. bills that make public plans the primary source of coverage such as medicare for all bills. these bills are an amalgam of provision that is individually or collectively have the potential to make the following changes in the health system, improve the affordible, benefits, and cost protection of insurance, slow cost growth in hospital and physician service, prescription drugs, and administrate yrgs. reduce the number of uninsured and under insured people. some notable estimates are the effects of these bill's provisions include lifting the top income eligible threshold for marketplace tax credits could ensure nearly two more million 350e78 and lower premiums by nearly 3% at a net federal cost of $10 billion. allowing h.h.s. to negotiate prescription drug prices under a medicare for all approach could lower drug prices by 4% to 40%
in medicare for all approach could lower administrative cost from a current 14% of spending in commercial plans to anywhere from 6% to 3.5% of all spending. the estimated effects of a medicare for all approach on u.s. health expenditures range from a decline of 10% to an increase of 17%. what has exaptured the most attention in the debate about compare for -- medicare for all is a significant shift in how health care being would be paid for. most medicare for all bill shifts most of the responsibility to the federal budget. this shift raises important combess about financing. in particular the incidents of taxation. what is notable about the range of national health expenditures estimates under medicare for all approach is that the increase in expenditures is often less than the increase in demand for health care induced by providing comprehensive coverage to everyone. these spending estimates vary widely because of assumptions about the degree of change in
provider prices, prescription drug cost, and administrative costs. the meck niches for slowing cost growth in these proposals could be considered refined and applied not only in single payer approaches but other health reform approaches as well. in the absence of congressional action on improving coverage, many states have stepped up and implemented policies such as reinsurance programs. improving coverage for everyone will ultimately require federal legislation. icks spanneding coverage, limiting family cost, and slowing cost growth are achievable goals and these bills provide mechanisms to move forward on each. i look forward to your questions. thank you. mr. mcgovern: than you very much. dr. brown is a retired doll nell in the u.s. army medical corps. and 118th president of the medical association. retired from the national medical institute where she managed the breast cancer chemo prevention portfolio. she was a wood wrow wilson public policy scholar in 2007
where her research focused on breast cancer health disparities. she now serves as the president and c.e.o. of brown and associates. a small business specializing in improving health outcomes. a brown graduated from college in mississippi. university of california in los angeles and georgetown university, m.d. she's a medical oncologist by training. we are thrilled to have you here. >> thank you. thank you chairman mcgovern, ranking member cole, and members of the committee. i thank you for the opportunity to appear before the committee to discuss universal health coverage for all americans, particularly the vulnerablely underserved population. dr. browne: i am here as the retired military medical officer and immediate past president of the national med can association, the largest and
oldest national corgs representing the interests of more than 30,000 african-american physicians and the patients we serve. as the nation only health care organization still devoted to the needs of african-american physicians and their patients weerks disturbed by the vast inequities of vulnerable populations. with numerous and often unsurmountable obstacles to receiving quality health care, people of color experience differences in access to care, the affordability of these service, and bias by some providers, and limited participation in clinical research which has consequences around valuable medical treatment. .
address some of those concerns. but given the disproportionate impact on chronic diseases in communities of color, congress must find ways to make health care coverage affordable, accessible, and of high quality for all. but the national medical association health care is more than a provision of medical services. health care is a multifocal, complex product which takes into account the critical determinants of health, including the socioeconomic conditions, housing, education, food and nutrition, environmental, exposures, genetics and biological factors. while the a.c.a. was a step in the right direction and made substantial improvements in our health care system, it did not go far enough. in order to stem the high prevalence, morbidity and
mortality of chronic diseases, we must first develop a comprehensive agenda around health equity, and health equity is the state in which everyone has the opportunity to attain their full health potential and no one is disadvantaged. it's imperative health care be provision to surpass one's socially defined circumstances. health equity and opportunity are inextricably linked. when health equity is achieved, there is no health disparities. and universal health coverage is a pathway to achieving that health equity. it has the potential to address poverty, inequality, and discrimination. it can also provide a more efficient and effective cost saving health care system for everyone. because health equity and opportunities are linked, the health equity, as i indicated, there will be no health
disparities. the government has maintained a track record for providing comprehensive health care throughout the military's tricare program, the department of veterans affairs, and other sponsored programs, as you know, medicare, medicaid, and others. and these programs have diligently worked to confirm affordable access to high-quality health care benefits for millions of citizens covered by these programs. under d.o.d.'s tricare, which is the second largest single payer health system in the country and second only to the v.a. program, both of these high-caliber systems adhere to high-quality, evidence-based, accessible care for their beneficiaries. a patient should not have to decide between getting their full prescription filled and whether they should buy food and, of course, that certainly is something that we've seen in the private sector, taking care of cancer patients, where they would decide, maybe i should
fill only part of the prescription. part care does not get you to remission in cancer. every patient should have the opportunity to receive first-class medical care rather than being considered second best because of a lack of insurance, provider bias, limitation of the medicaid system. we've seen this over and over where an individual may not get the approved drug for care in cancer but get the second best because their system did not have the drugs on the formulary. the best framework for universal health coverage is through collaboration and engagement of diverse partners, including the communities in which they serve. some of the existing health care programs already have the infrastructure and provider network to serve our communities. but improvement is needed to
target the excessive costs, service flexibility while minimizing the duplicate services we see in many cases. i want to leave you with two points. first, we must adopt a system of universal coverage that minimizes the administrative medical costs. it does not matter what label you use, whether it is medicare for all, universal health coverage, single payer, whatever. the coverage must be one that would allow the patient's ability to choose the provider for their care and care should be the same no matter whether you receive it in mississippi or california, whether you're in rural america or urban america, and it should not be restricted based upon language, age, gender, racial and ethnic areas. secondly, we must continue to address the physician shortage and funding of our safety net hospitals. universal health coverage would allow for increased investment in educating more providers and
allowing for additional residency slots. with consistent and predictable provider costs, we can end the two-tiered system of health care that has placed hospitals that serve low-income and minority communities at risk for closure. universal coverage would ensure that our safety net hospitals are sufficiently funded and resourced. they will continue the long history of advocacy and education. we believe that all individuals in every community in the united states have a right to equal, quality, high-quality health care that is accessible, affordable, comprehensive, and coordinated. we begin by providing the comprehensive coverage benefits that we have under medicare for all. thank you. griffey thank you very much. i want to -- mr. mcgovern: thank you very much. i want to introduce debbie dingell who arrived here.
she's co-author of the medicare for all bill along with congresswoman jayapal. we appreciate her leadership and her being here. last but certainly not least, dr. nahvi is an emergency medicine physician and assistant professor of medicine in new york city. dr. nahvi completed his m.d. at n.y. school of medicine and is on "now this" discussing his patient struggles with the current health care system and he's on the board of directors of the new york metro chapter of physicians for a natural health program. i would urge my colleagues to either google dr. nahvi and he has interesting and compelling videos that kind of highlight some of the inwases of the current city -- ined a cassies of the current system. -- inadequacies of the current system. dr. nahvi: is that too close? mr. mcgovern: it's good.
dr. nahvi: thank you, chairman mcgovern, ranking member cole. i'm an emergency medicine doctor in new york city and i support medicare for all. i have the opportunity to help all sorts of people in all sorts of ways. i get to save investment bankers from heart attacks and strokes and get to help with homeless veterans from hypothermia in the winter. that's what i love about my job. ed idea i can help any person with any problem at anytime is what attracted me to emergency medicine. it's hard to care for someone when they fear of bankruptcy and foreclosure when it comes to seeking medical care. ask any e.r. doctor, you will hear countless, countless stories of those who came to eek medical care only to leave a.m.a., against medical advice. they are concerned about the cost of their treatment. the reality for many people in
this country is that seeking medical care means weighing one's health against one's wallet. now, everyone in this room is very smart. everyone knows all the statistics. you already know that 41% of americans have skipped a visit to the e.r. because of cost concerns. we should let that sink in. that's 41% of americans. over two in five americans have skipped a visit they felt they needed to go to the e.r. but then decided not to go seek medical care because they were concern about the cost of that visit. you also already know 45% of americans live in fear that a health event could lead to bankruptcy. i have to look these patients in the eye and i want to put some face on the numbers you already know so well. few weeks ago, i took care of a patient who i was sure had an appendicitis. i discussed antibiotics and possibly surgery. she flagged me down, asked me to pull out her i.v. because she wanted to go home. now, she wasn't stupid, crazy,
didn't distrust doctors or anything. the patient was concerned about the cost of her treatment. she did research on her phone. learned in some rare cases an appendicitis can be treated with anti-buy ottics alone and asked to get a prescription. his is far, far from care of appendicitis. admission spital and possibly surgery. i strongly advised against her plan. now, she asked me about the risks and i told her the truth. i told her about the possibility of an abscess, sepsis from infection and even death. this is not an exaggeration. this is the truth if you don't treat an appendicitis. she thought about it for a long while but eventually she flagged me back down and decided to leave. she said, thanks, doc. i appreciate all you done. i really do. i just don't know if i will be able to afford this. i am going to go take my chances. now, in my line of work, i have
to give people bad news. i often tell loved ones that their family members have died. i have to tell parents their child has died, told spouses their husbands have died. i can tell you with complete sincerity watching someone sick, someone that is treatable, especially in the richest country in the world, is the awfulest feeling as any of those conversations. about one year ago i took care of a young lady who came in for an overdose. she decided to go to a local pet store to treat her symptoms. she wanted to make sure she was better for her interview. fish antibiotics. there is no instruction for human consumption. she ended up overdoses. she had side effects that affected her brain and central nervous system. she fell down a staircase while on the job interview and had to be admitted to the i.c.u. all that because she felt she
couldn't afford a simple visit to the e.r. for a simple fever. 21 years agos when she was 10 years old, my fiance, who is here with me right now, lost her mother because her mother decided to delay medical care until after her stomach cancer spread. my fiance's mother was worried about the cost of her care and she paid for it for her life. i am here tude because my patients and my fiance -- i am here today because my patients and my fiance deserve better than that. this should not be taking place in the richest country in the word. i am not asking for much. all i want to do is practice medicine so i don't have to watch patients walk out without care because they fear of going bankrupt or the best option for medical care is to go to the local pet store. to simply treat someone for something as simple as an
pend indicts or taking pet medication is radical ideas. this is something as easy as maintaining our roads, educating our students. we can create a universal health care system so when they are at their most vulnerable my patients don't have to make any consideration except do what they need to do in order to get better. thank you, chairman mcgovern, ranking member cole, and the rules committee for inviting me to be here. i look forward to any questions. mr. mcgovern: thank you. thank you all very much for testifying. before i ask some questions, i would ask unanimous consent request i want to enter in the record. you know, our health care system is built with checkpoints that prohibit a person from being able to access health care, including pre-authorization requirements, lifetime limits, network restrictions, costs and the inherent discrimination built in the system. i'd like to submit a letter from the national nurses
united, an organization with 150,000 members. their letter explains how gatekeeper obstacles would be eliminated with this bill, and who d like to jean ross, is with us here, for her leadership and her work and ensuring every american has access to affordable health care in this country. jean is here in washington, d.c., with nurses from 28 different states advocating for medicare for all. i want to thank you. without objection. without objection, i'd like to submit in the record a letter from diane archer, the founder and past president of the medicare right center which is a national nonprofit consumer service organization. in her letter she brings to light serious concerns about medicare advantage and how medicare for all, improved and expanded medicare system can fix these problems. and a child's access to health care is crucial. they're going through a time of rapid brain and body development and it's important their health coverage reflicts their needs. a recent survey by georgetown
center for children and families found an increase in uninsured children for the first time in a decade. so without objection, i'd like to submit a letter from a california-based nonprofit child advocacy organization working to ensure every child has access to health care. this letter outlines the critical components of health coverage and care for children that should be addressed in any policy congress considers, including medicare for all. i'd like to thank maya alvarez, president of the children's partnership. those will be in the record. so let me begin my questions. mr. barkann, let me ask you a question and i'll come back to you in a minute for the answer. but you know a little bit about how health insurance companies deny claims. and you testified that your medical bills cost thousands and thousands and thousands of dollars a month. you also talked about the time commitment it takes to fight back against these denials. i guess my question is, what
are some of the services or medical devices that were denied by your insurance company and how is your life impacted by not having those services? and i'll go to the next question and come back to you, ady, in a minute. let me, you know -- let me say to doctors baker, blahous and collins, you are all economists. tell me, are economists always right? [laughter] mr. mcgovern: i mean, you should try being a member of congress. we're always right, right? seriously, though, let's look at studies. even looking at dr. blahous' tudy from the conservative merkatus center. it seems like the studies suggest that medicare for all could cost a little more or a little less than we're currently paying now, right?
getting that right? dr. blahous: i think that's fair. mr. mcgovern: ok. so worst-case scenario, we could spend about what we are spending now nationally on health care and guarantee that another 29 million people get health care coverage. we could end crushing costs for everyone, and we could include new services for seniors and the disabled. that sounds like a pretty good deal to me. so i mean, when we have all these, you know, warnings about the high cost, we're spending an awful lot on health care right now. and we're not getting the services and the effectiveness that we're all demanding. so i just want to put that out there because i think -- i think it's important for people to put this all in perspective. i am not talking about new costs. we are talking about costs that are already built in the
system. dr. baker. dr. baker: i throw a quick point about economists not being right. i think the kari piiroinen hasn't gotten credit -- i think the affordable care act hasn't gotten credit. how much it deserves credit for the slow down in cost growth. if you go to 2008, the projections from the center for medicare and medicaid services for 2017, compare with what we actually spent, we spent 1.5 percentage points of g.d.p. less on health care than what they had projected. that comes to $300 billion that year. same thing if you look at the c.b.o. projections. we're spending half a percentage point less on medicare than what they projected in 2010 before the bill passed. now, whether you want to say the affordable care act was responsible for all that slowdown, that's a totally arguable point. the point is we're doing pretty good in terms of slowing the cost of health care cost growth if you like increased government involvement. mr. mcgovern: dr. collins. dr. collins: yeah. i just wanted to -- my testimony covers the range of estimates that are currently
out here, including dr. blahous'. what you do see is exactly what you said. some estimates show a decline in national health expend terse. -- expenditures. it depends on savings we can potentially get from provider prices, from prescription drug costs, from administrative costs. but i think one of the major contributions of the medicare for all bill is putting the issue out there on how much we're paying providers right now. i think that is a really critical issue. it's why we do see some savings in some of the estimates that we've seen of the medicare for all bills. it's a conversation that the country needs to have right now. and i think the differences and changes in expenditures under these approaches put a fine point on that issue. mr. mcgovern: look, all of us here as members of congress, we do casework too. casework mount of
that deals with crippling costs. i guess the point i am trying to make, i think to think we all believe we can do better and i'm just simply saying, when people push the panic buttons on cost, i mean, we're spending an awful lot right now and we're not getting the result we want. and i think, you know, to me medicare for all offers a better way to go forward and gives us more care. by the way, for senior citizens, it gives them medicare plus. they get a lot more than they're getting right now. i don't know, ady, are you ready? all right.
mr. barkan: i would have to pay full price. the company also denied me a brand new f.d.a. approved medicine to treat a.l.s. first of all, my plan doesn't cover long-term care and certainly have to pay for 24-hour care, which is incredibly expensive. in addition, my insurance company denied me a breathing assistant machine. health net ruled the ventilator and medicine provided by my neurologist was not necessary and i would have to pay full price. the company also denied me a brand new f.d.a. approved medicine to treat a.l.s. the first time i had to complain publicly and generate an outcry for them to reverse their decision. the second time i had to organize a protest at their headquarters. but most people don't have the ability to do that, and nobody should have the obligation to do that, but this is a big part of how insurance companies make
their money. they deny, delay, and wait for patients to give up. i believe that approximately one quarter of claims are denied. as a result, people get sick, get sicker and die. fundamentally, the priority for health insurance companies is to make a profit, but that is not in the public interest. by getting the profit mode out of the health care industry, we can focus on the real priority, delivering high-quality health care. mr. mcgovern: thank you. dr. nahvi. dr. nahvi: i just want to piggyback on that. do i think when health insurance companies deny claims, it's not only unethical, i just want to show a couple examples when it's kind of just financially stupid as well. i have a couple cases i'll share real quick. in my hospital recently there is a 28-year-old female that came in with a regular run-of-the-mill urinary tract infection. course of antibiotics, no quefment she was denied that
claim for antibiotics. no good reason was given why. she was charged $300 over the counter in cash. she could not afford it. she went to the other side of the pharmacy and bought cranberry juice. she ended upcoming into the hospital two days later septic, high heart rate, had to get admitted to the hospital and i.v.'d antibiotics. we denied $300 and now had to pay thousands of dollars. i had a patient come in, he was having a heart attack. his cardiologist came down and recognized him and started yelling at him. why did you stop taking the medication i told you cannot stop taking? he said six months ago i was admitted to the hospital with complications from my diabetes medication. had to inologist said i take those. because we insufficiently covered these patient's prescription medications we
ended up paying more in the long run. another example, there is a patient i had, she was 38 years old. had a long history of depression. her depression was controlled with some psyche medications. out of nowhere she had been on these medications for many years. her medical insurance company started denying that medication. she stopped taking them. couldn't get in to see her psychiatrist for a month or two. she ended upcoming in because she was feeling suicidal and had to be admitted. the patient had bad medical outcomes and that's horrible in and of itself but it just financially doesn't make any sense. we ended up paying more for these bad outcomes. that needs to be part of the discussion as well. when you talk about all these estimates of cost, i imagine that the kind of cost savings we would see by making sure patients are covered and fully covered, we don't see that in these numbers because there's no way to account what we're seeing on the ground level. we would save a lot of money. mr. mcgovern: dr. browne.
dr. browne: well, certainly in the on colk area we see this most particularly with -- oncology area we see this most particularly with with people of color. they fear going to the doctor because they will deny that lump is there and think it will go away and many cases they will pray it away but after coming in after being denied it disease. nced the outcome is negative because they tend not to survive. mr. mcgovern: you indicated, again, you're paying all these thousands of dollars of these medical bills and you talked about a go fund me page to help you cover the cost. if you didn't go -- if you didn't have go fund me, what other household costs or family bills might not get covered to cover your care? you're a pretty popular guy. and even i have seen your twitter feed and know all about
your work. relying on go fund me might be something that someone of your stature can do, but not everybody can do that. what if you don't have the twitter following you have? what if -- how would you afford the care? and do you think there's anything sane about our go fund me health care system? while you think of that answer, nahvi.about to dr. you know, based on your testimonies, i'm guessing the stories of insurance companies denying care isn't surprising, right? dr. browne, you're a cancer specialist. can you tell the committee how a prepaid system like the military compares to a postpaid system like the one for the civilian population, how it differs when it comes to patients getting the care they need and actually following the doctor's best medical advice? dr. nahvi, you testified about your patients who put cost
before their health care out of necessity and fear and you told some horrible stories here. do you believe you are free to practice the best medicine you can, that your patients are free to take your advice without fear, or do you think there's something standing between you and your patients are getting the care they deserve? dr. browne: yes. in the prepaid system in the military, as a military provider, whether it is cancer or general internal medicine, it's equal access system and we do not have to be concerned with can that patient afford an m.r.i. or should i just order an x-ray? again, i know that the best possible care is what i can provide for those patients and so i order the m.r.i. and get the best care for those individuals. they don't look at, do i have a co-pay? is there some out of pocket? they go to that facility in the integrated system and they get
the best care. if you're outside, you weigh that. maybe i should see if a cat scan will suffice and i can still see the dimensions of this mass and its distinguishing features to whether i should order surgery. if the patient cannot afford for even a c.t. scan, then i look at whether the other kinds of things that i can order to get that patient to the care they need. and that is not the way i was trained to practice medicine. you go in to provide the best possible care for those patients and it's not based upon cost. it's based upon need. so you can improve the health outcomes. mr. mcgovern: dr. nahvi. dr. nahvi: i couldn't agree more. the answer to your question is, no, i don't think i'm practicing the best medicine i can practice. i feel like i'm practicing with one hand tied behind my act. oftentimes when i recommend something to my patients, they sit down and they think, can i afford this, should i do it
before they decide to do it or not. these are lose-lose conversations. i feel if i try to tell somebody to do something and say, no, i don't think i can afford that cat scan, they walk out, their health suffers. even if i convince them, i don't feel terribly good about myself. if i convince someone to get a cat scan they don't think they can afford, i walk away thinking, did i just kind of sentence this person to years of debt they are not going to be able to pay off? there's no winning in a lot of these conversations and i am not giving the best care. mr. mcgovern: mr. barkan. mr. barkan: if i couldn't use go fund me i would probably start asking my parents to start spending down their retirement savings. then, we would go hand in hand to friends. no one dealing with a serious illness should have to do either of these things. we should instead have a rational, fair, comprehensive social safety net that actually catches us when we fall. mr. mcgovern: thank you. mr. cole.
mr. cole: thank you very much, mr. chairman. if i may, i will follow your lead here. i want to submit a letter, without objection, from the american hospital association in opposition to the legislation. mr. mcgovern: without objection. mr. cole: thank you very much, mr. chairman. if i could start with you. h.r. 1384 explicitly makes it illegal for private health insurers to provide for a service that the government would provide under this legislation. how many people would lose the current health insurance if they have if we did something like that? >> 173 million americans with job-based health insurance but those on the a.c.a. coverage, people on medicare, people on medicaid, the children's health insurance program, all would be medicare to the new for all legislation. mr. cole: if you like your plan, liked what you have, you
wouldn't have any option at all to keep it? ms. turner: only if you are in v.a. or the indian health service, as i understand it. mr. cole: believe me, people in the indian health service might make the change. ms. turner: oklahoma used. mr. cole: depends what congress does and doesn't do in that service. anyway, let me ask this in follow-up to that. how would this impact both employers who provide the coverage and employees who are satisfied with -- what they are actually receiving? ms. turner: i think this is really a significant issue and it's one when colorado tried to enact, to try -- a ballot initiative in 2016 to try to create a single payer system for the state of colorado, they did wind up with serious pushback from people who didn't understand what it meant they would lose their private coverage. they would particularly lose their employer coverage. the employer-based system is
really a central pillar in our health sector for a number of reasons. because employers have easier access to health care for plotes with different health plan options. they listen to their employees, what benefits they need, what matters, always trying to balance the cost against benefits and trying to get the best deal for them. they also have a lot of wellness programs. they know a healthy workforce is beneficial to them. so they invest a lot in their employees. but i think there are two other points that are really crucially important. one is that because employers pay more for private coverage, they in turn pay more to hospitals, doctors, providers in order to make sure their employees have access to the care and the treatment they need. by paying them more, it allows medicare and medicaid to pay
less so that people on those public programs will also be able to access care. so there's a real balancing and i think the value of the employer-based health insurance, 473 million people, half of the people in the country, retirees, workers, dependents, etc., are really helping support the current medicare system that we're talking about amealiating. also, because employers get a tax break, as providing health insurance as part of the compensation package for nair employees, there's a tax break there. also, employees have -- the value of their health insurance is excluded from their income. the value of employer-sponsored health insurance is about 991 billion dollars. almost $1 trillion in 2016. and there is a tax break worth
about $350 billion to support employer-based health insurance. so that tax break supports 3-1 and some estimates are even higher. health insurance for half of the country in order to get private payers to contribute to that health insurance. i think that equation, something that's developed over 70 years in this country, it's unique to america but perhaps that's because we, through some limitations of history, started on that path. it's something people enormously value and it really has become a central pillar in our health sector. mr. cole: your answer, i anticipated a lot of my next question, but let me put it to you this way and get your response on this as well. if we, as there are bill calls for, held the reimbursement rates for providers and
medicare and medicaid levels, how would that impact the providers? what do you think the response would be? ms. turner: i'm not an economist. i am a policy person, but the former actuary for c.m.s. anticipated when congress was considering and actually enacted cuts to medicare providers, when we were still having the doc fix battles, if hospitals and physicians were to see 40% payment cuts, many of them simply could not keep their doors open. they do not have that kind of margin. they would either dramatically curtail services or they would wind up closing their doors. mr. cole: you're sitting right next to an economist. [laughter] mr. cole: i would ask dr. blahous for his response to the same question. dr. blahous: i think the honest answer is the effects are unpredictable. we do know the datea. we do know the data indicates
payments for hospitals over the time window, first 10 years of medicare for all, medicare payment rates are 40% below private insurance rates. for physicians they are about 30% below at the beginning of that 10-year period. those relative reductions under the macra law would be 42% by the end of 10 years. the honest answer is we have no idea how providers would respond to this. we do know roughly under the legislation, the demand for health services would increase by probably about 11%. other studies made similar estimates. and if we make simultaneous, very dramatic reductions in payment rates to providers at the same time as this increase in demand, none of us can say for certain how they would respond. we do know from the medicare actuary offices that medicare payment rates, that the margins on treating medicare patients are negative for about 80% for hospitals and medicare for all would extend that situation to the population as a whole. how providers would react to
that, what sort of disruptions there might be in the timeliness or quality or supply of health services, we simply don't know. mr. cole: let me ask you this because we all know that not all hospitals are equally profitable or serve populations that are equally of a lieutenant. certainly in my district, -- affluent. certainly in my district, we lost rural hospitals in recent years. they're treating a population that's older, quite often sicker and enjoys less private coverage so they rely very heavily on medicare and medicaid and they're having a tough go. again, if we remove that, suggest know the impact wouldn't be equal all across the country. in other words, i think rural areas, in particular, would take a pretty hard hit unless something was done to change the rates, is that fair? dr. blahous: i think that's fair. i just -- to add additional perspective on this from the vantagepoint of my study, my main reason for flagging this
issue is primarily just to help with understanding of the numbers. we have a set of cost estimates that would arise if you assume these very dramatic payment reductions were implemented, right from the get-go, right from the very first year but if you look at the historical patterns of congressional behavior, you don't see a willingness to impose sudden cuts for providers or anything close to that magnitude. if you think those hiss corecal patterns of congressional -- historical patterns of congressional behavior would continue, the cost estimate of the legislation would be much, much higher. it would be in the area of $38 trillion. mr. cole: let me ask you this. i will address to all of you, if i may. we'll start actually down here and go across. this is enormously complex undertaking we are talking about, to change the entire health care system. i lived through one of these things with fisa, as many of my
colleagues did, the discussion, debate, and then implementation of obamacare, the a.c.a. is two years a sufficient period of time? that's what the legislation calls for, as i understand it. within two years we would make this entire transition. is that a realistic, even for those of you that want to go in this direction, worry about the time frame? >> i would have to say you have to be cautious. two years is ambitious. you're referring to your hospitals as largely rural and they already have a large number of medicare patients, if that's the case, they are less likely to be in danger because they are already getting reimbursed at medicare rates. mr. cole: they also get private payments as well. >> i understand. smaller share. mr. cole: every patient they treated, medicare and medicaid levels, i promise you most of them would close. dr. baker: i can't comment. may well be true. dr. collins: i think the
transition issue, you can certainly decide to extend it, make it a longer period of time. the a.c.a. was a four-year transition period, so that's certainly something you could consider. i did want to say -- address the cost shift argument in the medicare payment area. it is the evidence really does not show that the reason that private provider prices are higher is because medicare prices are so slow. if that were the case we would see consistently higher margins all the way across the country. instead, we see a lot of variability across the country. so the way this works is that private providers are negotiating with their commercial care -- with commercial carriers, prices that work the best for them. in concentrated markets they get higher prices. insurers want them in their network, want them in their network so they concede to those higher prices. they then take those -- that negotiated rate to employers.
employers have to pay higher premiums. they reduce the workers' wages, incess deductibles so those costs get shifted ultimately to people. there's not a lot of evidence that the cost shift argument is a reason for higher prices. it's really these nontransparent price negotiations that occur in the rivate market. mr. cole: yes, absolutely. mr. barkan: you asked earlier, we don't expect employers to provide their workers with education for their children or with fire insurance. there is no reason to tie health care to employment. it just exacerbates the negative impact of job loss and, frankly, it's a huge burden on employers. mr. cole: thank you. dr. browne. mr. barkan: yes. just wanted to -- dr. browne: yes, just wanted to add, in terms of people of
color, medicare and medicaid reimbursement costs are not the same across the board. our providers are already getting a lower rate. it's not likely they are going to go out of business. in terms of employers and the amount that's being paid, many of the smaller businesses go to part-time individuals so they do not have to carry that cost. so, again, i think for providers we are concerned about, they are not going to walk out on taking care of their patients even though they are getting a lower rate. mr. cole: dr. nahvi. dr. nahvi: sure. i assume you ask a question from an implementation perspective but from a physician perspective, we are ready for this, not in two years, but two years ago. i am ready to stop seeing my patients not get good care because they can't afford things. >> i'll answer the question from the federal cost perspective, when did i my study i was dealing with a bill that had a four-year
transition. dr. blahous: and was not able -- did not feel myself able to score the effects during that four-year transition period because very unpredictable factors like transition costs, voluntary buy-in rates, things like that. and so for simplicity sake, i assumed in that fourth year everything just instantly sprang forth fully formed, that we instantly have cost savings, we had a level shiftdown ward in prescription drug costs, we instantly had the full implementation of these provider cuts. you can look at that and say those may be reasons why the lower bound estimates, even assuming a four-year transition, would be an understatement. if you had a two-year transition, obviously that increases the likelihood that the lower-bound estimate is a gross understatement because there's probably very little chance that we would attain those instant administrative
cost savings, those instant drug cost savings i am assuming in the lower-bound estimate. mr. barkan: representative, may i weigh in on that? mr. cole: i have very little time left. if i have time left i will come back to you. ms. turner: mr. cole, there was a good piece in today's "washington post" about vermont's experience and i think it's instructive. they took an in-depth look at the experience -- their experience in trying to achieve a single payer health care system. green mountain care, they worked for four years and were unable to figure out how to structure it. for the small state of vermont to figure out how providers would be paid, how the taxes would be collected. d the -- what they found was that the initial projections took what she calls a 36,000-foot view what the costs
were going to be. when they really got down to the hard wiring of the implementation, they found it would be so disruptive to the state's economy and so disruptive of the current structure of the health care system they had to pull the plug on it. she said it's very difficult to dismantle one health care system and replace it with another. mr. cole: may i -- ok. mr. barkan, please. mr. barkan: here's what i know for sure. i needed medicare for all to be in effect yesterday. if the richest nation in the history of the world really decided to, we could guarantee health care as a right and we could probably do it more quickly than people think. but the problem is that right now we're not even trying. too many people in the halls of this building are trying to accept the status quo. that leaves people like me behind. mr. cole: thank you very much. thank you, mr. chairman. mr. mcgovern: thank you very much. i want to yield myself a minute here just to make a couple
points to ampify ady's point, employer-sponsored health care means the effects of job loss are amplified. it puts a huge burden on employers. imagine if we expected employers to provide for fire insurance, as mentioned, police insurance, school funding for k-12, paperwork that's all part of it. it's insane. just one other point here. because i think what some of us are looking at this whole initiative from a different per expective, people won't lose their health care with medicare for all -- perspective, people won't lose their health care with medicare for all. you can keep your doctors, go to your hospitals you currently have. the only difference is you won't have to deal with insurance companies. i don't know about you but that's not my favorite thing to do when i get sick. anyway, i now yield to my good friend, mr. perlmutter. mr. perlmutter: i just want to thank this panel, everybody. the professionalism in your testimony is very much appreciated by this congressman
and i know the rules committee generally -- mr. barkan, couple questions for you. you know, you talk a lot about time. another guy in a chair like you, stephen hawkings, you wrote a number of essays on time. but time is really a key piece to all of this and you talked about a number of things. the effect of taking time and the waste of time on you personally. i'd like you to expand on that a little bit and then you also said we could save enormous sums of money. i'd like you to expand on that. and then you said, we could avoid immoral price gouging. i think those were your words. i'm just putting those three things that you talked about, i'd ask you to, pand. now, to the economists, i'd like to talk a little bit more the money in the health
care system, is the biggest part of our economy in its own right. health care system 1920, 21%. 18%. whatever it is, it's far bigger than anything else. so my first question, i guess to you, dr. baker, and dr. collins is -- how does that percentage of our overall economy compare to the rest of the world, other countries, industrialized countries? and i guess to all of you -- and dr. blahous, to you as well -- the overall savings that we might expect from something like this. there was an economist, bob pollin, and his approach to these things, because it's a
massive change. and why do we want to undergo a massive change if we're not going to save some money and have better outcomes? and i'll get to you doctors, medical doctors in a second, to talk about the outcomes. and then ms. turner, just so you know, i am going to talk about colorado. i'll tee that up to you. dr. baker: 18% of our g.d.p. is on health care and that's twice the average. if you take a lower cost system like the u.k., we could finance that whole system from what we spend now in the public sector. that's how much we are out of line with everyone else. and you know, the point i think that's striking, on the one hand we have huge administrative costs but the other point i was trying to emphasize in both my comments and written testimony, we pay twice as much for the inputs. twice as much for the drugs, for the medical equipment, doctors, on down the list. and, again, that's not true of our cars. it's not true of our auto workers. so you're hard pressed to say, why do we have to pay twice as
much for drugs as everyone else? we don't pay twice as much for our cups here and cars here? but we do. that i think speaks to the enormous potential savings. again, i understand none of that -- you are the ones that have to fight with these people because these income for people. what does it look like for the u.s. compared to everyone else, we're paying twice as much. dr. collins: i'd just echo dr. baker's comments. we have a -- there's a chart in our testimony that shows the details on the countries that pay so much less than we do. but i would also make the point, our point, too, we also don't get commensurate outcomes for the spending that we're making. we actually have worse outcomes in a number of areas that other countries that are spending far less. so the quality issue is a huge issue internationally as well. mr. perlmutter: dr. blahous, i appreciate your testimony when
mr. mcgovern was talking maybe it's a push, maybe it's a little bit of a loss, maybe a little bit of a gain. this dr. pollin, i guess, economist from the university of massachusetts, thinks there's a big savings. do you have any comments on that? dr. blahous: well, sure. if i could try to unpack it a little bit. mr. perlmutter: sure. dr. blahous: i want to build off some of the things that dr. baker and dr. collins have said. i think it was well stated by dr. baker that most of the costs from the federal perspective are a shift. they're a shift from costs now being borne by the private sector to the federal government. i would add to that, the federal government would be assuming costs that are currently borne by state and local governments. it's not just the private sector. it's all of that. it's a shift. that's a big piece of the cost. now, there are other things that would increase costs beyond that. and i thought dr. collins said something earlier where it was useful where she said basically the total national cost increase would be less than the
utilization increase. so in other words, the biggest part of this cost increase is an increase in service demand and utilization. now, maybe we can cut into some of those in favor say aye crease by savings on administrative costs, savings on drug prices, things like that. now, we won't be able to offset those costs with those measures and that's where the cuts to provider payments come in. the question is, would we be able to cut provider payments enough to offset that additional cost? mr. perlmutter: and i think dr. nahvi mentioned this and in somebody else's papers, you know, two out of five people don't take advantage of health care, their need for health care because of fear of expense, that they walk back out and he gave some dramatic examples. in effect, there is a lot of demand that's not being met because people are afraid of the cost. so i was a bankruptcy lawyer
for many, many years before i was elected to congress. obviously one of the biggest areas of bankruptcy is because of health care costs. so i do appreciate your comments, dr. nahvi, when you said, yeah, i may convince somebody to stay there but now have i saddled them with some debt that could cause a ankruptcy or something else? there are all sorts of issues here, but i think, to dr. brourn and to dr. nahvi -- browne and to dr. nahvi and then to dr. pollin's estimates, if we were to go to this medicare for all or universal health care system, do you agree that there would be more demand on the system? can we -- could we, from a provider standpoint, manage that? mr. barkan: thank you.
yes. i think -- dr. browne: thank you. yes. i don't think there would necessarily be a demand on the system. i think would you practice medicine in a more appropriate, better way. and the idea is that you are going to increase your educational components for your patients and practice prevention. if you put prevention into practice, you're not going to have many of those hospitalizations that will end up in the intensive care units. and so there are cost savings there. we have not practiced prevention, and we have been talking about it for years and years, and it's just going to the wayside. if we get people to come in and to do their immunizations and get those standard tests of screening, so screening and early detection, find the diseases at an earlier stage. again, you can then provide that care at a more cost-effective. so the demand is not going to increase. we're practicing care in a more
efficient way. dr. nahvi: yeah. i'd like to echo that. so i gave you a couple examples of people that came in, didn't get the care they needed and ended up having more expensive care. there will be some people using more care. we can utilize the health care system. i see a lot of people come in with late stage disease because they didn't get to go to their primary care doctor when they needed to and then we end up paying more than that. e reason is we have a law, emergency medical treatment which makes it such anyone uninsured, undocumented, whoever they are, they could come to the e.r. and we treat them. if they can't foot the bill the taxpayers foot the bill or the hospital does. i think if we expand coverage, we get these people utilizing care at the right places. they end up going to the primary care doctors get their diabetes, high cholesterol
under control so they don't have strokes. mr. perlmutter: do you think a system like that would help you avoid paperwork? [laughter] dr. browne: yes. mr. perlmutter: ms. turner and then i'd like to go to mr. barkan, and i appreciated your testimony because you really laid it out as to 70 years ago it was you paid out of your pocket or you got charity care and a lot of that charity care was underwritten by the churches, by charitable organizations, and then kaiser came along and said people are getting hurt, we got to do a war effort and so kaiser steel and kaiser aluminum and those guys -- they started the employer system. so we are in this massive system and to change it is obviously a big undertaking. so i agree with all of that. with respect to colorado -- so i am from colorado.
and i support ms. jayapal's legislation. i support the -- briefing -- beefing up the affordable care act. there san effort out there that says anybody 50 and older you can buy into the medicare system. so i think all are improvements over where we are today. but my question to you on vermont and on colorado, just as a voter on that, i voted against the legislation because i didn't think colorado, on its own, could undertake a complare for all -- medicare for all system. that it was national in scope. and that's why i went this way. but i'm happy to have you comment on it a little bit more. ms. turner: just briefly, you know more about the debate in colorado than i do. in vermont, they were assuming that much of the money that currently is flowing to the state through health care,
whether it was employer contributions, whether it was a.c.a. funds, existing taxes, etc., all would be part of that. so they were assuming a much larger pot of money because there would be additional federal funds coming in, and they still couldn't make it work. i know in colorado that there were -- from my reading on it, and did i a couple debates about the ballot initiative, the feedback we continually got was people so nervous about the taxes that would be required to support it and, yes, they -- there were arguments that the current money going to employer-based health insurance would be go but that just wasn't enough. mr. perlmutter: i think you're right. from a policy and kind of a political standpoint, it wasn't enough to overcome a number of the concerns and fears. but i think listening to the testimony of the economists and the doctors, and just, you
know, our own experience. my wife had a difficult surgery. initially denied. i mean, i can't tell you the panic that hits a family when something like that happens. you know, there are all sorts of issues. i'm just pleased there mr. pollin and mr. mcgovern were able to work out the details -- mr. cole and mr. mcgovern were ble to work out the details to have this hearing. mr. barkan, are you ready for my questions. mr. barkan: thanks very much for your questions. this health care system only works if you're a pharmaceutical or insurance industry executive who wants to maximize their own profit at the expense of people like me. it is simply unconscionable i should have to pay $9,000 per month for a lifesaving medical care at the time when the insurance industry is bringing in record profits.
that's wrong and it needs to stop. here's the thing. it's a huge trust to -- >> live coverage of this hearing continues on our companion network, c-span3. also on c-span.org. members today considering financial literacy programs. live to the house. [captions copyright national cable satellite corp. 2019] [captioning performed by the national captioning institute, which is responsible for its caption content and accuracy. visit ncicap.org] hardy kim, sunnyvale presbyterian church, sunnyvale, california. the chaplain: let us pray. holy god, we give you thanks for this day filled with vibrant life, proosking -- proving your ongoing care for all creation. we thank you for the members of this house, for the gifts they bear, the communities they represent, and the varied spiritual journeys that have formed them. grant each of them understanding of your divine truth, that they might wisely lead us along paths of righteousness.